When caring for more than the patient becomes a constraint for task performance

In what follows, it is scrutinised how five interruptions affect the interactivity further. First, the nurse interrupts the doctor-patient interaction as she makes herself heard above their conversation and second an incoming call interrupts several times and it eventually prompts the doctor to abruptly drop the conversation completely. Despite the two previous interruptions, the patient continues her narrative even though the doctor only reads in the sheet (see picture E). The patient is interrupted three times in just one sentence (line 14, 15 and 16).

Almost immediately after the patient resumes her narrative (line 13), the nurse interrupts as she asks the medical laboratory assistant for some specific information (line 14). The distance between the nurse and the medical laboratory assistant prompts the nurse to speak over the patient. No one is paying direct attention to the patient, but each team member (the medical laboratory assistant, the nurse and the doctor) is occupied with individual tasks that are valued higher than the dialogue with the patient. The patient, however, does not stop talking, but mumbles something unrecognisable into the nowhere, when the phone rings and interrupts her verbal utterance. The patient appears oblivious to the interruptions and she continues her narrative in direct continuation with the ringing and as she finalises her utterance: to the toilet ri[ght she is interrupted for the third time by a second ringing.

At 01:32:50 there is an overlap of interruptions. The patient seeks confirmation: ri[ght as the phone rings and the doctor utters [yes, (line 17). The doctor has gazed in the sheet for 17.70 seconds and as he responds to the patient’s statement in line 13 he does not gaze at the patient, rather he briefly gazes at the phone’s display on which the incoming number appears (see picture D), but he still does not respond to the call, even though its ringing prompts his orientation to a third element in the diagnostic event. The phone interruption is thus defined as a secondary event pivot that leads to a second change in the interactivity as the stress level increases further: the doctor needs to engage in dialogue, comprehend the information on the sheet, interpret the relevance of the incoming call and perceive the situation as a whole in order to decide how he should respond to the multiple disturbances.

In figure 7.2 this is indicated as: stressed multi-tasking.

At that moment the doctor struggles to balance multiple activities simultaneously: taking the patient’s history, reading in the sheet and containing the interruptions. The patient is persistent and continues to ignore the ringing and completes a point in her narrative: and then I had to call my daughter who says to me mum this is not (.) (line 18). As she starts her utterance, the doctor gazes on the phone, but as the patient holds her breath for a short moment (.) the doctor gazes at the patient again who continues: this is not [(xxx). As the patient utters something unrecognisable she is interrupted for the third time by the ringing

phone, which still does not prevent the patient from finalising her utterance: it is blood=

(line 18). The doctor immediately follows up on this utterance and repeats the patient’s last three words: =it is blood, and continues: I have to take this one (line 20). He then responds to the call, walks away from the patient and gazes out in the room as he speaks on the phone (see picture E).

The final ringing is identified as the primary event pivot that leads to a task-switch. In figure 7.2 its consequences are defined as changes in the interactivity trajectory and the change is characterised as: history-taking on stand-by. As the doctor finally responds to the incoming call and leaves the room, he re-enacts a value hierarchy that leads to the breakdown of the cognitive system, both functionally (goal-orientation) and interpersonally (seeking good prospects). In my data, dysfunctional interactions often emerge as a person has low multi-task tolerance. In this case, the cognitive event is characterised by multiple event pivots that finally lead to a task-switch (see figure 7.2). As this doctor is forced to respond to multiple demands within the cognitive system, he loses overview. The interesting questions are why the doctor chooses to answer the phone call during another task and secondly why it – when he chooses to do so - takes him such a long time to respond to the incoming call? The cognitive patient-doctor system is constituted by moral values such as caring and trust, and it is a dialogical and situational system that only exists for a limited time. However, the doctor is also morally and socially obliged to maintain a relationship to non-local, though long-lasting social systems, for instance systems that include other colleagues and management staff.²⁷ Such systems consist of values that guide healthcare professionals’ behaviour even though they are not physically present (Bang and Døør, 2007). “Humans are always interdependent with others, although the degree and kinds of interdependencies will of course vary with individuals, cultures and situations”

(Linell, 2009:13).

For the doctor to maintain a good reputation he is dependent on organisational credibility, which he achieves by being sensitive to social systems and responding to the phone call interruption. As non-local relationships matter in local interaction, it has consequences whether team members follow protocols and orders or not. The phone call symbolises an anonymous ‘other’ (Linell, 2009), and depending on how the abstract and trans-situational other is managed, it guides the local actions in a certain direction. In this context it means that the doctor is expected to respond when a superior seeks contact. If he chooses not to do so, he can be reprimanded. Answering the call thus realises important values within the social system. As caring within the social system is achieved by responding to the call, caring within the dialogical system is realised by not-responding to the call. A dilemma emerges, as the doctor is unable to engage in dialogue and respond to the interruption at the same time. As the doctor sees no other solutions to the dilemma, he needs to choose between caring for the dialogical system or the social. The doctor hesitates and postpones answering the call, which indicates a double sensitivity towards both local                                                                                                                

  27 Confer section 3.3.1 for an elaboration of Steffensen’s definition of dialogical and social systems (Steffensen, 2012).

interaction and non-local expectations. However, the stress level increases: the phone has rung three times and will soon stop ringing. If he does not respond in time, his behaviour could be categorised as inattentive from a social systemic perspective. Further, while the patient might have felt the interruptions as constraints for dialogical interaction, her

‘ignorance strategy’ enables her to treat the first six interruptions as non-interruptive. Her strategy complicates the doctor’s possibilities for managing the interruptions as interruptive as this strategy requires that he interrupts the patient and undermines her strategy. If the patient had oriented to the interruptions as such, conditions for dialogical coordination were better, as there would be a shared agreement about the situation’s complexity. That the doctor does not respond immediately to the call is thus interpreted as a sign of caring for the patient even though his behaviour appears hesitant and non-engaging. The main problem with the doctor’s behaviour when he becomes stressed by the pressure of time (the third and last ringing), is that he is forced to find the first possible completion point and interrupt the patient by announcing that he is going to respond to the call (line 20). The second problem relates to the way he manages the phone call. Before the doctor leaves the room, he orients to the nurse and asks for permission to leave for a short moment as he points towards the door (see picture F). The nurse agrees and the doctor leaves without informing the patient, without looking at her, and without letting her know what happens and for how long he will be gone.

Together the number of interruptions adds up and results in a task switch (see figure 7.2), and it attests to how the doctor, in the end, prioritises the organisational system and its authorities at the expense of dialogue with the patient. The situation changes as disturbances within the interactivity trajectory make the cognitive system disintegrate and reorganise its boundaries; in this case with a dysfunctional outcome in consequence. While the doctor is cognitively overloaded by the disintegration, the patient is emotionally affected: she withdraws and she does not respond to the doctor’s explanation: I have to take this one (line 20). Rather, she stares vacantly into space without gazing at the doctor or responding to the announcement.

From the moment the patient arrives the medical team still does not know what caused the severe rectal bleeding, and it is a serious medical condition. Thus, from a patient perspective, the interaction with the doctor does not reflect much understanding and the logic of the system are not immediately transparent, explicit or caring: “all doctors and health systems purport to put patients first, but ample evidence shows that it often doesn't feel that way to patients. They regularly feel like cases rather than people, and what is important to patients is often different from what is important to doctors” (Smith, 2003:1433). The doctor’s performance appears irrational and insensitive since the patient, in the end, is valued lowest in a diagnostic situation. Paradoxically, the negative outcome overshadows the multiple failed attempts to maintain a dialogical relation with the patient.